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SOAP Note#19
S

Pt reports sharp pain LLQ x2 wks. Cold triggers. No spontaneous pain at rest. Pain 6/10.

O

Perc + #19. Cold test lingering 12s. EPT exaggerated. PA: widened PDL mesial apex.

A

Symptomatic irreversible pulpitis #19 with symptomatic apical periodontitis.

P

NSRCT #19. Risks/benefits discussed. Informed consent obtained. Referral letter sent.

Consultation#19
CC

Referred by Dr. Chen for endo eval #19. Sharp pain with cold beverages x2 weeks.

Hx

No prior endo tx. Existing MOD composite #19 placed ~3 yrs ago. No trauma hx.

Exam

Perc +, palp WNL, cold +/lingering, EPT exaggerated vs contralateral.

Imp

Irreversible pulpitis. Recommend NSRCT. Pt consents.

Progress Note#19
Tx

NSRCT #19 completed. LA: 2% lido w/ 1:100k epi, IAN block + long buccal.

Proc

Access through existing MOD. 3 canals (MB, ML, D). WL confirmed w/ apex locator.

Fill

Canals obturated WVC + BC sealer. Final PA confirms adequate obturation.

Post

Pt tolerated well. Post-op instructions given. F/U with GP in 2-4 wks.

Exam Record#19
Vitals

BP 128/82. HR 72. No known allergies. Current meds: none reported.

Extra

No facial asymmetry. No lymphadenopathy. TMJ WNL bilaterally.

Intra

Soft tissues WNL. Existing MOD composite #19, marginal breakdown noted.

Rad

PA #19: widened PDL mesial apex. No periapical radiolucency. No root resorption.

Treatment Plan#19
Dx

Symptomatic irreversible pulpitis #19. Symptomatic apical periodontitis.

Tx1

NSRCT #19. D3330. Est. 1 visit. LA + rubber dam isolation.

Tx2

Temp restoration post-endo. Refer back to GP for permanent crown.

Alt

Extraction + implant/bridge. Pt declines. Elects RCT. Consent signed.

Billing Note#19
Code

D3330. Endo therapy, molar. D0220. PA radiograph.

Ins

Delta Dental PPO. Member ID: DDQ-4892731. Pre-auth submitted 03/14.

Est

Patient responsibility est. $340 after insurance. Copay collected at visit.

Note

Pre-auth approved 03/16. Claim submitted 03/21 post-treatment.

Apex Endodontics

1240 University Ave, Suite 300 · Montreal, QC H3B 0G4 · (514) 555-0142

LETTER

March 14, 2026

To: Dr. Sarah Chen, DDS

Smile Dental · 580 Sherbrooke St W, Montreal

RE: Endodontic Evaluation. Patient James Smith (DOB 04/12/1985). Tooth #19

Dear Dr. Chen,

Thank you for referring Mr. Smith for endodontic evaluation of tooth #19. The patient presented with sharp, spontaneous pain in the lower left quadrant persisting for approximately two weeks, with heightened sensitivity to cold stimuli. No history of trauma reported.

Clinical Findings

Cold test: lingering response, 12 seconds. Significantly prolonged
Percussion: positive on #19, negative on adjacent teeth
Palpation: within normal limits, no swelling or sinus tract
Periapical radiograph: widened PDL space at mesial root apex
EPT: exaggerated response compared to contralateral tooth

Diagnosis

Symptomatic irreversible pulpitis, tooth #19, with symptomatic apical periodontitis

Treatment Plan

Non-surgical root canal therapy is recommended. The patient has been informed of risks, benefits, and alternatives and has provided informed consent. Prognosis is favorable. We will coordinate scheduling with your office directly.

Sincerely,

Dr. Michael Torres, DMD, MS

Board Certified Endodontist · Apex Endodontics

Generated by Marea

Ref: RFL-2026-0314-019

Apex Endodontics

1240 University Ave, Suite 300 · Montreal, QC H3B 0G4 · (514) 555-0142

TREATMENT SUMMARY

March 21, 2026

To: James Smith

RE: Root Canal Therapy. Tooth #19 (Lower Left First Molar)

Dear Mr. Smith,

This letter summarizes the endodontic treatment completed on your lower left first molar (tooth #19) on March 21, 2026. The procedure was performed by Dr. Michael Torres under local anesthesia.

Procedure Details

Three canals were located (mesiobuccal, mesiolingual, distal), cleaned and shaped using rotary NiTi instrumentation, and obturated with gutta-percha and bioceramic sealer. The procedure was completed in a single visit with no complications. You tolerated the procedure well throughout.

Follow-Up Instructions

1.Return to Dr. Chen within 2-4 weeks for permanent restoration
2.Full-coverage crown is recommended for long-term prognosis
3.Avoid chewing hard foods on the treated side for 48 hours
4.Mild discomfort is normal. Take ibuprofen 400mg as needed
5.Contact our office immediately if you experience increasing pain, swelling, or fever

The prognosis for tooth #19 is favorable. A 6-month follow-up radiograph will be taken to confirm periapical healing.

Sincerely,

Dr. Michael Torres, DMD, MS

Board Certified Endodontist

Generated by Marea

Ref: TXS-2026-0321-019

Apex Endodontics

NPI: 1234567890 · Tax ID: 98-7654321 · 1240 University Ave, Suite 300

PRE-AUTHORIZATION

March 14, 2026

To: Delta Dental Insurance. Claims Department

Member: James Smith
DOB: 04/12/1985
Member ID: DDQ-4892731
Group #: GRP-10248

To Whom It May Concern,

Pre-authorization is requested for non-surgical root canal therapy on tooth #19 for the above-referenced member. This letter documents the clinical necessity of the proposed treatment.

D3330

CDT Code

Endodontic therapy, molar (excluding final restoration)

Clinical Justification

Prolonged cold response (12 seconds with lingering pain)
Positive percussion sensitivity, negative on adjacent teeth
Widened PDL space on periapical radiograph (attached)
Existing MOD composite with marginal breakdown and recurrent decay

Treatment is medically necessary to preserve the natural dentition. Delay may result in acute abscess, cellulitis, or tooth loss requiring extraction and prosthetic replacement at significantly higher cost to the plan.

Sincerely,

Dr. Michael Torres, DMD, MS

NPI: 1234567890

Enc: PA radiograph, pulp test

Ref: INS-2026-0314-019

Apex Endodontics

1240 University Ave, Suite 300 · Montreal, QC H3B 0G4 · (514) 555-0142

POST-OP REPORT

March 21, 2026

To: Dr. Sarah Chen, DDS

RE: Post-Operative Report. James Smith. Tooth #19

Dear Dr. Chen,

Root canal therapy on tooth #19 was completed on March 21, 2026. Below is a summary of procedure details and findings for your records.

Canals
MB, ML, D. Negotiated to WL via electronic apex locator
Instrumentation
Rotary NiTi files, crown-down technique, sizes 20-40/.06
Irrigation
5.25% NaOCl, 17% EDTA, final rinse with saline
Obturation
Warm vertical condensation, bioceramic sealer (BC Sealer)
Restoration
Temporary: Cavit + flowable composite overlay

Diagnosis

Previously vital tooth. Symptomatic irreversible pulpitis with symptomatic apical periodontitis, #19

Recommendations

Restore with full-coverage crown at earliest convenience. 6-month recall radiograph to assess periapical healing. Prognosis: favorable.

Sincerely,

Dr. Michael Torres, DMD, MS

Board Certified Endodontist

Generated by Marea

Ref: POR-2026-0321-019

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